eMedicine Specialties > Gastroenterology > Esophagus
Esophageal Hematoma
Updated: Jul 20, 2006
Introduction
Background
Esophageal hematoma is a rare condition that can be spontaneous or secondary to trauma, toxic ingestion, or medical intervention.
Marks and Keet reported a case of a spontaneous intramural hematoma of the esophagus in 1968. This uncommon condition has now been well documented in the literature.
Pathophysiology
Vomiting can lead to increased intraesophageal pressure that may result in mucosal tears (Mallory-Weiss syndrome), transmural perforation (Boerhaave syndrome), or intramural hematoma of the esophagus. The hemorrhage occurs within submucosal tissues.
Intrinsic esophageal disease, such as achalasia, is rare in patients with esophageal hematoma.
Esophageal hematoma may occur at various sites of the esophagus. The mechanism producing the hematoma may determine the site. For example, a hematoma from vomiting would be in the region of the esophagogastric junction, and a hematoma from a caustic substance might be at points of narrowing.
Mortality/Morbidity
- If the hematoma is associated with a perforation of the esophagus, septic complications (eg, mediastinitis, abscess formation) are likely to occur.
- The mortality rate associated with esophageal perforations is about 10-20%.
Sex
Approximately 80% of intramural hematomas occur in women.
Age
Primarily middle-aged women are affected. In a literature review of 31 patients, the mean age was 67 years.
Clinical
History
- Spontaneous intramural hematoma of the esophagus usually presents initially with severe retrosternal or epigastric pain with or without radiation. The pain is described as abrupt in onset and is aggravated by swallowing.
- In one meta-analysis, 32% of patients presented with the triad of chest pain, hematemesis, and dysphagia; 99% of patients had at least one of these symptoms.
Physical
A complete and thorough physical examination should be performed.
- Asking a patient to take a sip of water as part of the general examination may help to unmask symptoms of dysphagia. This may help toward distinguishing between cardiac chest pain and an esophageal disorder causing chest pain.
- Palpation looking for the presence of crepitus (suggesting the presence of air under the skin) along the neck, back, and chest can help to rule in or out the presence of an esophageal perforation.
Causes
Esophageal hematomas typically occur in the setting of vomiting or retching, although spontaneous hematomas (more commonly in patients with bleeding disorders) may also occur.
- Precipitating or predisposing factors to esophageal hematoma include the following:
- Coagulopathies, such as hemophilia, or treatment with anticoagulants or aspirin
- Instrumentation, such as with endoscopy or variceal sclerotherapy
- Foreign body ingestion
- Chest trauma
- Food-induced injury, as a result of abrasive trauma by foodstuffs
- Cardioversion and subsequent anticoagulation
- Toxin ingestion
Differential Diagnoses
| Boerhaave Syndrome | Myocardial Infarction |
| Esophageal Cancer | Pulmonary Embolism |
| Esophageal Rupture | |
| Esophageal Varices | |
| Mallory-Weiss Tear |
Other Problems to Be Considered
Dissection of the thoracic aorta
Aortoesophageal fistula
Workup
Laboratory Studies
- The laboratory workup should include hemoglobin concentration and coagulation profile with platelet count.
- Cardiac enzymes and troponin levels should be drawn to exclude a cardiac cause for the patient's chest pain.
Imaging Studies
- Chest radiograph
- Chest radiographs may reveal a broadened mediastinal mass or bilateral pleural effusions.
- Preliminary study helps to exclude a perforation and other pathologies included in the differential diagnosis of chest pain.
- Barium swallow (esophagram)
- Typically, this study helps to confirm the diagnosis, revealing a filling defect in the mid and lower esophagus, usually on the posterior wall, with luminal narrowing and sometimes with mucosal irregularity.
- Extravasation into the mediastinum is not observed unless a perforation has occurred.
- A double barrel sign or a mucosal stripe sign may be demonstrated, that is, double columns of contrast medium separated by a radiolucent stripe and a large intramural mass that reflects a mucosal dissection that allows extravasation of contrast material into the hematoma.
- CT scan with contrast
- CT scan reveals a nonenhancing, eccentric, well-defined, intramural esophageal mass that has the density of blood.
- CT scan can help to better characterize esophagram findings, accurately define the extent of intramural dissection, and exclude esophageal perforation.
- CT scan is useful in excluding other conditions that may mimic esophageal hematoma, including mass lesions, aortic dissection, and pulmonary embolism.
- MRI
- MRI can help demonstrate the extent of the hematoma in various planes and can help rule out additional mediastinal pathology.
- MRI is indicated for patients who cannot have a CT scan because of an allergy to iodinated contrast medium or renal impairment.
- An endoscopic ultrasound (EUS) shows an intramural hypoechoic submucosal mass.
Procedures
- Upper endoscopy
- It has been suggested that fiberoptic endoscopy is relatively contraindicated in the further evaluation of esophageal hematoma because many intramural hematomas are contained perforations that could be worsened by the insufflation of air.
- Others endorse the use of endoscopy in the initial evaluation once esophageal perforation has been ruled out.
- Endoscopically, an esophageal hematoma is described as a bluish or purplish colored, submucosal mass protruding into the esophageal lumen.
- Endoscopy can precisely identify the tear in the mucosa, but the risk of the procedure should be weighed against the need for this information and the generally uncomplicated course that these patients follow.
Treatment
Medical Care
For spontaneous intramural hematoma, conservative therapy leads to an excellent prognosis. Esophageal hematomas generally resolve within 2-3 weeks with no long-term sequelae.
- Nothing by mouth (NPO) for the first several days. Oral intake should be reintroduced gradually. A soft diet may be started in a stable patient on days 4-6. Parenteral feeding is generally not required, as most patients are able to swallow within a few days.
- Provide intravenous fluids while the patient is NPO and transfusion of blood if needed.
- Acid suppression should also be considered to reduce the risk of esophageal ulceration.
- Antiemetics are indicated as needed.
- Correction of any coagulation abnormalities is indicated.
- Occasionally, extensive esophageal hematomas have been treated by sclerosant injections.
- Because this entity is so rare, a clear indication for this therapeutic approach has not yet been established.
- Complications during endoscopic sclerotherapy include rupture of the intramural hematoma.
Surgical Care
- Surgery is only indicated in patients with massive ongoing hematemesis. This occurred in 19% of patients, as reported in a literature review of 31 patients with esophageal hematoma.
- Via a right thoracotomy, an esophagotomy may expose the bleeding tissue, which is then oversewn.
Consultations
- Cardiologist
- Gastroenterologist
- Thoracic surgeon
Medication
Acid suppression by histamine 2 (H2)-receptor antagonists or proton pump inhibitors is useful to treat or prevent esophageal ulcerations.
Proton pump inhibitors
Inhibit gastric acid secretion by inhibition of the H+/K+/ATP-ase enzyme system in the gastric parietal cells. These agents are used in cases of severe esophagitis and in patients not responding to H2-antagonist therapy.
Omeprazole (Prilosec)
Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ -ATP pump.
Dosing
Adult
20-40 mg PO qd before breakfast
Pediatric
Not established
Interactions
May decrease effects of itraconazole and ketoconazole; may increase toxicity of warfarin, digoxin, and phenytoin
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Bioavailability may increase in elderly patients
Lansoprazole (Prevacid)
Inhibits gastric acid secretion. Used for up to 4 wk to treat and relieve symptoms of active duodenal ulcers.
Dosing
Adult
30 mg PO qd before breakfast
Pediatric
Not established
Interactions
May decrease effects of ketoconazole and itraconazole; may increase theophylline clearance
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Consider adjusting dose in liver impairment. Prolonged treatment (typically > 3 years) may lead to vitamin B12 malabsorption
Rabeprazole (Aciphex)
Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ -ATP pump.
Dosing
Adult
20-mg tab PO qd
Pediatric
Not established
Interactions
May decrease effects of itraconazole and ketoconazole; may increase toxicity of warfarin, digoxin, and phenytoin
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Symptomatic relief with proton pump inhibitors may mask symptoms of gastric malignancy Prolonged treatment (typically > 3 years) may lead to vitamin B12 malabsorption
Esomeprazole magnesium (Nexium)
S-isomer of omeprazole. Inhibits gastric acid secretion by inhibiting H+/K+ -ATP pump at secretory surface of gastric parietal cells.
Dosing
Adult
20-40 mg PO qd
20-40 mg IV qd IV over 10-30 min or by injection over at least three min
Pediatric
Not established
Interactions
Amoxicillin or clarithromycin may increase plasma levels of esomeprazole when used concurrently; may reduce absorption of dapsone; may increase levels of diazepam and GI absorption of digoxin; may decrease absorption of iron, ketoconazole, and itraconazole
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Symptomatic relief with proton pump inhibitors may mask symptoms of gastric malignancy Prolonged treatment (typically > 3 years) may lead to vitamin B12 malabsorption
Pantoprazole Sodium (Protonix)
Inhibits gastric acid secretion by inhibiting H+/K+ -ATP pump at secretory surface of gastric parietal cells.
Dosing
Adult
40 mg PO /IV qd
Pediatric
Not established
Interactions
May decrease effects of itraconazole and ketoconazole; may increase toxicity of warfarin, digoxin, and phenytoin
Contraindications
Hypersensitivity to pantoprazole, substituted benzamidazoles (ie, esomeprazole, lansoprazole, omeprazole, rabeprazole), or any component of the formulation
Precautions
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Symptomatic relief with proton pump inhibitors may mask symptoms of gastric malignancy Prolonged treatment (typically > 3 years) may lead to vitamin B12 malabsorption
H2-receptor antagonists
Reversible competitive blockers of histamine at the H2 receptors, particularly those in the gastric parietal cells where they inhibit acid secretion. The H2 antagonists are highly selective, do not affect the H1 receptors, and are not anticholinergic agents.
Ranitidine (Zantac)
Inhibits histamine stimulation of the H2 receptor in gastric parietal cells, which in turn reduces gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Dosing
Adult
150 mg PO bid; not to exceed 600 mg/d
Alternatively, 50 mg/dose IV/IM q6-8h
Pediatric
Not established
Interactions
May decrease effects of ketoconazole and itraconazole; may alter serum levels of ferrous sulfate, diazepam, nondepolarizing muscle relaxants, and oxaprozin
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Caution in renal or liver impairment; if changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
Famotidine (Pepcid)
Competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Dosing
Adult
40 mg/d PO bid
Alternatively, 20 mg IV bid
Pediatric
Not established
Interactions
May decrease effects of ketoconazole and itraconazole
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
If changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
Nizatidine (Axid)
Competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Dosing
Adult
300 mg PO hs or 150 mg bid
Pediatric
Not established
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in renal or liver impairment; if changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
Cimetidine (Tagamet)
Competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Dosing
Adult
150 mg PO qid; not to exceed 600 mg/d
Alternatively, 50 mg/dose IV/IM q6-8h; not to exceed 400 mg/d
Pediatric
Not established
Interactions
Can increase blood levels of theophylline, warfarin, tricyclic antidepressants, triamterene, phenytoin, quinidine, propranolol, metronidazole, procainamide, and lidocaine
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Elderly patients may experience confusional states; may cause impotence and gynecomastia in young males; may increase levels of many drugs; adjust dose or discontinue treatment if changes in renal function occur
Follow-up
Further Inpatient Care
- Follow-up care after the acute event has resolved with either a barium swallow or endoscopy is necessary to rule out any additional esophageal disease not seen on the initial evaluation. This can be done prior to discharge or can be arranged to be done on an outpatient basis.
Complications
- Full-thickness perforations of the esophageal wall have been reported during endoscopy of an esophageal hematoma.
Prognosis
- Long-term results are very good with conservative and supportive treatment.
- Intermittent odynophagia usually subsides within 2 weeks after the primary event.
- Recurrence is extremely rare.
Miscellaneous
Medicolegal Pitfalls
- Distinguishing esophageal hematoma from cardiac ischemia or pulmonary embolism is critical because esophageal hematoma can be worsened by thrombolysis and anticoagulation.
- In contrast to an intramural esophageal hematoma, an aortoesophageal fistula is a life-threatening condition that may present as a submucosal esophageal hematoma. On endoscopy, an aortoesophageal fistula is noted as a pulsatile esophageal mass. The prognosis is grave if surgical intervention is delayed.
- Filling defects on the esophagogram have been confused with tumors. Conversely, a follow-up endoscopy or barium swallow should be performed to ensure that a tumor or other esophageal pathology was not missed on the initial evaluation.
- Aortic dissection is a surgical emergency that must also be distinguished from esophageal hematoma in the initial evaluation.
- Monitor for the development of a fever or pleural effusions, which may indicate an esophageal perforation missed during the initial evaluation.
References
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Keywords
esophageal apoplexy, esophageal mucosal tears, Mallory-Weiss syndrome, transmural perforation, Boerhaave syndrome, intramural hematoma of the esophagus, esophageal perforation, mediastinitis, abscess formation, vomiting, dysphagia, odynophagia, hematemesis, severe acute chest pain
Contributor Information and Disclosures
Author
Jennifer Lynn Bonheur, MD, Fellow, Department of Internal Medicine, Division of Gastroenterology, Lenox Hill Hospital
Jennifer Lynn Bonheur, MD is a member of the following medical societies: American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, New York Academy of Sciences, and Sigma Xi
Disclosure: Nothing to disclose.
Coauthor(s)
Klaus Radebold, MD, PhD, Research Associate, Department of Surgery, Yale University School of Medicine
Klaus Radebold, MD, PhD is a member of the following medical societies: American Gastroenterological Association and New York Academy of Sciences
Disclosure: Nothing to disclose.
Medical Editor
Maurice A Cerulli, MD, FACG, Chief, Division of Gastroenterology and Hepatology, Associate Professor of Clinical Medicine, Department of Internal Medicine, Division of Gastroenterology, New York Methodist Hospital, Cornell University
Maurice A Cerulli, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Medical Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.
Managing Editor
Simmy Bank, MD, Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine
Disclosure: Nothing to disclose.
CME Editor
Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.
Chief Editor
Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
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